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..,.",:v,\i,f',(li;;..... County <br /> Safety and Buildings Division /,�4U—it)C7tf <br /> 1400 E Washington Ave <br /> t, 9 Sanitary Permit Number(to be filled in by Ca. <br /> I 'I P.O.Box 7162 SpN-a1 -3h6 �oudGy3 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> 9w1s- ‘12.103138 G <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> - <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary -2 9 <br /> / <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / / . �to <br /> I. Application Information-Please Paint a'1 Information PPS'-3,•e,4-- <br /> c <br /> Property Own fir's Name ( <br /> Parcel# c? 7 0,;.2e' a yo 16 c <br /> Fr ► KS ) 0 ✓I >e <br /> ii07,1 r � rl3[ <br /> GZ L c- / T i o/?o349 <br /> Property Owner's Mailing Address Property Location <br /> AO- Q°A I /V Govt.Lot <br /> City,State I -� / Zip Code PhoneNumber <br /> __.6 <br /> /, '/4, Section a� <br /> b3 t?U 5/ e Gt/'7 j 1.J �1 _) 377-.753 T �G N; RJ‘(etrcle one E <br /> III.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> Subdivision Name <br /> JJ' (//ti t- Block# <br /> sE,ubiic/Commercial-Describe Use /9131/I ✓G j ciy/04/ •__- <br /> ❑City of <br /> CSM Number ❑Village ofd� n <br /> ❑State Owned-Describe Use //"own of Q k/l�/tyC,;Y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i ❑New System .Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I .V <br /> 7 <br /> 1 <br /> 1B• 1 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> PT.Type of POWTS System/Component/Device: (Check all that apply) <br /> iF Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(se Dispersal Area Proposed(sf) System Elevation <br /> f V0 a -7 a 9' a).. �6.,‘. <br /> I STI.fink Info { Capacity in Total #of Manufacturer <br /> j I Gallons Gallons Units p U ,b, <br /> New Tanks Existing Tanks 5, 'e. L U y m <br /> a.U in co w c7 a, <br /> Septic or PieMT1rTank 5' • l C r <br /> l i r� <br /> Dosing Chamber /2 So j /.02.5 <br /> �. / /' <br /> "IIIc.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM / <br /> j'�n(�//--� /./ / 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) ( <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issui A• nt Si• .e <br /> Approved ❑ Disapproved a Od / //��/ <br /> I ❑ Owner Given Reason for Denial $L12 r• I?/?1 ? ..1".."....04°"11111.9.- <br /> ..--..,,,-- <br /> 1.7(:. <br /> / / <br /> l .Conditions of Approval/Reasons for Disapproval ��� <br /> D ,E © COMG <br /> Silas. isglb <br /> HFC 2 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not I a 1/2 x 11 inches in size <br /> SBD-6398(R0313) Burnett County <br /> Land Services Department <br />